Provider First Line Business Practice Location Address:
1885 25TH ST SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97302-1105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-588-2395
Provider Business Practice Location Address Fax Number:
503-588-8011
Provider Enumeration Date:
05/21/2012